Title of the article:

Model of parental acceptance of various behavior management techniques used in pediatric dentistry

Abstract:

Purpose: to evaluate the parental acceptance of different behavior management techniques routinely used in pediatric dentistry.

Methods: Forty parents were shown a video tape of different nine behavior management techniques. (1.) Tell Show Do, (2.) Modeling, (3.) Positive reinforcement, (4.) Distraction, (5.) Voice control, (6.) Hand over mouth exercise, (7.) physical restrain, (8.) conscious sedation and (9.) General Anesthesia. Parents were explained and asked to rate their acceptance on visual analogue scale provided in form

Results: All the parents in the sample group completed the survey form and among them 37 parents accepted the positive reinforcement technique as the most acceptable. The least acceptable techniques were Hand over mouth exercise and physical restrain. The acceptance rate was in following order: Positive Reinforcement, Tell Show Do, Distraction, Modeling, Conscious Sedation, General Anesthesia, Voice Control, Hand over Mouth Exercise, Physical Restrain.

Conclusion: Parents favor more affirmative approaches and management techniques that engross demonstrations geared for the child’s level of accepting. Aversive conditioning like Physical Restraint, Hand over mouth exercise and voice control is more strongly rejected than sedation and general anesthesia.

Introduction:

The most imperative facet in pediatric dental practice is behavior management of the child. It saves the time of not only dentists but also parents and child. The successful results can be obtained by the less anxious and well managed child. (Wright G Z. Behavior Management in Dentistry for Children. Philadelphia, WB Saunders Co, 1975) And for managing such child, the number of behavior management techniques has been explained in the literature.

The intimate relationship among child, parent, dentist and society has been well explained by pedodontic triangle which provides proper child dental care. Not only this, but also it provides the information regarding the behavior management techniques to be used against the child. (Wright G Z. Behavior Management in Dentistry for Children. Philadelphia, WB Saunders Co, 1975. )(American academy of pediatric dentistry: Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2007;29:115‑24.) According to Kupietzky, for better understanding for their children`s treatment, parents can also participate actively in treatment decisions, and various behavior management techniques to modify their children`s behavior. This will ultimately diminish the parental anxiety. (Kupietzky A. Effects of video information on parental preoperative anxiety level and their perception of conscious sedation vs. general anesthesia for the dental treatment of their young child. J Clin Pediatr Dent 2006;31:90‑2) with growing concern about children`s rights and considering ethical aspects, pedodontists can no longer take for granted that parents will endorse any form of behaviour management technique without issue. (Klein A. Physical restraint, informed consent and the child patient. J Dent Child; 55: 121-122. 1987, Lawrence S M, McTigue D J, Wilson S, Odom J G, Waggoner W F, Fields H W Jr. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent; 13: 151-155. 1991.)

Informed consent is having a growing blow on behavior management of children. The courts uphold that treatment by health care professionals without prior consent is array and the dentist who treats a patient devoid of consent may be liable (Brown 1976). It was stated in the conference sponsored by American academy of pediatric dentistry in 1988 that informed consent must be obtained prior to employ any behavior management technique in children. (American Academy of Pediatric Dentistry: Behavior Management for the Pediatric Dental Patient — Final Proceedings of a Workshop,September 30 – October 2, 1988, Iowa City, IA.) There are few studies which demonstrate that behavior management techniques are not evenly acknowledged by parents or guardians and many techniques are found to be objectionable. (Murphy M G, Fields H W Jr, Machen J B. Parental acceptance of pediatric dentistry behavior management technique. Pediatr Dent; 6: 193-198. 1984. , Peretz B, Zadik D. Attitudes of parents toward their presence in the treat­ment room during dental treatment to their children. J Clin Pediatr Dent; 23: 27-30. 1998.)

Various studies have been done regarding acceptance of various behavior management techniques in children. It begins with the study done by Murphy et at who first encountered in differences in parental acceptance of behaviour-management techniques. In their study, they fulfilled that tell-show-do technique was customary by most parents and general anesthesia and aversive conditioning techniques like physical restrain were least accepted. (Murphy MG, Fields HW, Machen JB. Parental acceptance of paediatric dentistry behavior management techniques. Pediatr Dent 1984; 6: 193-8.) Seven years after this study another study done by the Laurence et al stated that the enough explanation is necessary for better understanding and acceptance each techniques by parents. (Lawrence SM, McTigue DJ, Wilson S, et al. Parental attitudes toward behavior management techniques used in paediatric dentistry. Pediatr Dent 1991; 13: 151-5.) Havelka in 1992 quoted in his study that the socioeconomic status also influence the acceptance of certain behavioral modification technique by parents. (Havelka C, McTigue D, Wilson S, Odom J. The influence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent 1992; 14: 376-81). Also, the acceptance of each behavior management technique is influenced by culture and geographic region. (Long N. The changing nature of parenting in America. Pediatr Dent 2004; 26: 121-4.)

Till now there is only one Indian study was there regarding acceptance behavioral management techniques by parents. (Elango I, Baweja DK, Shivaprakash PK. Parental acceptance of pediatric behavior management techniques: A comparative study. J Indian Soc Pedod Prev Dent 2012;30:195-200)

Thus, understanding parental acceptance regarding various behavior management techniques are very important which will ensure the proper child-dentist relationship as well as providing proper care. So the aim of this study was to assess the attitudes of parents towards different behavior management techniques used in pediatric dentistry.

Materials and methods:

40 Parents were randomly selected from the department of pedodontics and preventive dentistry after the institutional committee ethical approval. (KA/PD- 06/2013) The inclusion criteria was decided which were, Parents of children with age 4-15 years with no previous dental history, Parents who are willing to participate and able to view and understand the videotape and Parents of all socioeconomic status irrespective of their age, gender, income, educational status, and occupation.

A master video tape of various 9 behavior management techniques was made using the software windows movie maker v3.6. the behavior management techniques used were: (1.) Tell Show Do, (2.) Modeling, (3.) Positive reinforcement, (4.) Distraction, (5.) Voice control, (6.) Hand over mouth exercise, (7.) physical restrain, (8.) conscious sedation and (9.) General Anesthesia. All the behavior management techniques which were shown in the master video tape were recorded in the department of pedodontics and preventive dentistry. Before each behavior management, it was explained. The master video tape was approved by four pedodontist having more than 10 years of experience. The techniques were presented in the same sequence to all parents as follows:

1	Tell show do
2	Modeling
3	Distraction
4	Positive reinforcement
5	Voice control
6	Hand over mouth exercise
7	Physical restrain
8	Conscious sedation
9	General anesthesia

The video tape was 8 minutes long duration with each technique describing 20-30 seconds. After watching each behavior management technique parents were asked to give the opinion. The assessment form was filled by the parents contained the names of the techniques with two parameters of the visual analogue scale: Acceptable, Not acceptable

Videotape was projected using a laptop/ projector in the parent counseling room.() The subjects were asked to mark their opinion by using a vertical mark onto  or  Following each technique

Results:

According to data analysis, the positive reinforcement was the most acceptable technique that was accepted by 37 parents (92.5%). The least acceptable technique was hand over mouth exercise and physical restrain that was accepted by only 5 parents (12.5%). The acceptance of various other behavior management techniques was in following order.(table 1) The same result is shown in the following bar diagram. (figure 3)

No.	Technique Of Behavior Management	Acceptance By Parents	Rejection By Parents	Chi Square P Value	Acceptance (%)
1	Positive Reinforcement	37	3	<0.0001	92.5
2	Tell Show Do	35	5	<0.0001	87.5
3	Distraction	34	6	<0.0001	85
4	Modeling	31	9	0.0005	77.5
5	Conscious Sedation	10	30	0.0016	25
6	General Anesthesia	10	30	0.0016	25
7	Voice Control	7	33	<0.0001	17.5
8	Hand Over Mouth Exercise	5	35	<0.0001	12.5
9	Physical Registrant	5	35	<0.0001	12.5

Discussion:

In the past years, various studies were conducted regarding the parental acceptance of various behavior management techniques by Murphy et al, Lawrence et al, Frankel, ; Havelka et al.; Scott and García-Godoy; Eaton et al, Elango et al. According to this study, the most acceptable techniques are positive reinforcement (92.5%) and tell show do (87.5%). These findings are in correlation with previous study done by Murphy et al. The reason for the highest rating of positive reinforcement and tell show do technique may be the parent demanding for the more child friendly behavior that will inspire the child for future dental treatment.

Also in Murphy`s study, it was showed that the sedation and general anesthesia was least acceptable by parents. (Murphy MG, Fields HW Jr, Machen JB. Parental acceptance of pediatric behavior management techniques. Pediatr Dent 1984;6:193‑8.) But in our study, General anesthesia and conscious sedation both were selected by 25 % of parents. The reason may be, they don’t want their child cry in the dental clinic and want multiple dental treatment in single sitting. It was concluded in the study by Eaton et al that in recent years, the approval for permission of nitrous oxide sedation has increased. (Eaton JJ, McTigue DJ, Fields HW, Beck FM. Attitudes of contemporary parents toward behavior management techniques used in paediatric dentistry. Pediatr Dent 2005; 27: 107-13.) However in our study we found that a considerable number of parents (25%) approved this technique, which was more than the previous studies by Murphy.

The least acceptable techniques are hand over mouth exercise (12.5%) and physical restrain (12.5%) These findings are in correlation with previous studies done by Murphy et al. [1984] Eaton et al [2005] and J. Luis de León et al [2010]. The reason for the same may be parents consider these techniques as illegal, unprofessional and not child friendly. HOME technique is also facing some controversy over a long period of time. For this reason many pedodontists are not using this technique and believe that parents may react negatively if they use this technique. (Bowers LT. The legality of using hand-over-mouth exercise for management of child behavior. J Dent Child 1982; 49: 257-65.) According to the report by Ouesis (2010) although HOME technique is eliminated from the AAPD guidelines, many dentists still accept this technique. (Oueis HS, Ralstrom E, Miriyala V, Molinari GE, Cassamassinmo P. Alternatives for Hand Over Mouth Exercise after its elimination from the clinical guidelines of the American Academy of Paediatric Dentistry. Pediatr Dent 2010;32:223-8)

Restrain the child by pediwrap was also the least accepted technique. However it was suggested by frankle that this technique can be the accepted techniques by the mother if the child ic un cooperative. (Frankel RI. The Papoose Board and mothers’ attitudes following its use. Pediatr Dent 1991; 13: 284-8)

Limitations:

As the coin has two sides, the limitation in this study should not be ruled out. The first is different parents might evaluate the video tape differently and second one is failure to analyze the stress level of parents during watching the video tape. Further studies can be donre to eliminate these limitations.

Conclusion:

The following two conclusions can be drawn from this study,

1. Parents prefer more positive approaches and management techniques that involve demonstrations geared for the child’s level of understanding.
2. Aversive conditioning like Physical Restraint, Hand over mouth exercise and voice control is more strongly rejected than sedation and general anesthesia.